Ranges

Question 1

INR

Answer 1

Normal range of healthy patient 0.8-1.2
Normal range of Warfarin patient 2.0-3.0
Thin
8.0 means the blood will take 8 times longer to clot.

Question 2

Ketones

Answer 2

If BM’s are > 17 or repeatedly > 13 check Ketones
Normal range 0.6

3.0 Dangerous levels of Ketones requires immediate care.

Question 3

Troponin levels

Answer 3

Normal range 30ng/l

Question 4

PVC

Answer 4

1- possible phlebitis
2- early signs
3- med
4- advance
5-advance

Question 5

NEWS

Answer 5

0-4 4 hrly
5-6 1hrly + med informed
>7 escalate CCOT (Critical out reach team), bleep 0104, + registrar

Question 6

Bristol Stool

Answer 6

1-3 formed
4-5 soft form
6- mushy bits
7- watery

Question 7

Waterlow score

Answer 7

> 10 at risk
15 high risk
20 very high risk

Question 8

BM Range

Answer 8

Normal range 4-8

> After meals

Question 9

GCS

Answer 9

> 13 minor

8,9-12 moderate

Question 10

CIWA Score

Answer 10

0-9 Minimal
10-19 Mild to Moderate
>20 Sever withdrawal

Question 11

Falls Risk

Answer 11

> 13 high risk

Question 12

Pressure Ulcers

Answer 12

Grade 1- Non Blanchable Erythema
Grade 2- Partial thickness skin loss or blister
Grade 3- Full thickness skin loss
Grade 4- Full thickness skin loss exposing bone, tendon or muscle
Unstageable- Full thickness skin/tissue loss where depth of ulcer is obscured by Slough or necrotic tissue. It could be grade 3-4 if debrided.